Morris Infinite Healthcare Services Incorporated

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to electronically transmit completed OASIS (a standardized data set that measures the quality and outcomes of home health patients) assessments to the CMS system for all Medicare patients within 30 days of completing the OASIS assessment of the beneficiary (patients) for 52.21% (213 of 408) of assessments transmitted during 10/01/2023 – 10/14/2024. This failure prevented the agency’s patient data from being made available to CMS within 30 days of the OASIS completion dates for analysis to identify agency performance levels in the provision of patient care. Findings included: During pre-survey activity on 10/14/2024: The surveyor reviewed the agency OASIS report titled, “HHA Error Summary by Agency” from IQIES (an internet-based system that includes survey and certification functions) during the one-year of 10/01/2023 – 10/14/2024. The HHA Error Summary by Agency report included 213 of 408 OASIS assessments (52.21%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment. An interview was conducted with the ADM/DON on 10/14/2024 at 12.20 pm. The ADM/DON said she was responsible for OASIS assessment submission to the CMS system. An interview was conducted with the ADM and Alt DON on 10/14/2024 at 3.30 PM and the surveyor reviewed the error summary report which included 52.21% OASIS assessments submitted late. The DON stated she received it late for review from the RN who did the OASIS assessments, which resulted in the agency not following its policy. The surveyor asked what tracking system DOM had to ensure timely submission of assessments. The ADM said she was re-orienting and re-training the nurse for timely return of the assessments. Agency Policy titled, “Timelines IM.35” with a revision date of 05/02/2024, read in part, “…Purpose To establish timely parameters for all medical record information… Procedure… II. All completed and encoded OASIS data will be transmitted… to the CMS collection site within 30 days of the M0090 date…””

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review, observation and interview, the agency failed to coordinate missed skilled PT and OT evaluation and visits with the patient’s Physician in two (Patient # 1, and 2) of 5 active skilled patient records reviewed. Failure of the agency to ensure the clinical record included effective interchange and coordination placed patients at risk of negative patient care outcomes to meet the patient-specific health needs. Findings include: Patient record # 1: Record review of the electronic health record included a Plan of Care (POC) with a start of care (SOC) date of 06/03/2024 and a certification period from 08/02/2024 thru 09/30/2024. The POC revealed Patient 1 has the following diagnosis: “Essential Primary Hypertension, Hemiplegia (partial or total loss of muscle function in one or more parts of the body) affecting right dominant side, generalized muscle weakness, unsteadiness on feet, … “. The POC was electronically signed by the RN A on 08/02/2024. The POC included physician orders for PT and OT evaluation and treat. The electronic record included a PT referral sent on 08/20/2024 requesting “PT to continue as per Re-Eval”. 1. Patient’s entire clinical record did not include a PT evaluation or re-evaluation. There was no documentation of why the PT services were not provided staring the week of 08/02/2024. 2. Patient’s entire clinical record did not include an OT evaluation or treatment performed. There was no documentation of why the OT services were not provided staring the week of 08/02/2024. Further review of Patient 1’s record revealed there was no interchange of coordination of care delivery with the physician of delay in PT and OT referral and PT and OT evaluation and treatment. During home visit on 10/15/2024 at approximately 9.45 am, in an interview with Patient 1, the patient said he was not receiving PT or OT services. Patient said he need PT because he has muscle weakness, right sided weakness, unstable gait and had multiple falls. Patient stated he requested DON, and the nurse practitioner that he wanted outpatient therapy, but he was informed the insurance was delaying it. Patient record # 2: Record review of the electronic health record included a Plan of Care (POC) with a start of care 08/21/2024 and a certification period from 08/21/2024 thru 10/19/2024. The POC revealed Patient 2 has the following diagnosis: “Essential Primary Hypertension, generalized muscle weakness, Scoliosis, … “. The POC was electronically signed by the RN A on 08/21/2024. The POC included physician orders for PT and OT evaluation and treat. Further review of the electronic record PT and OT referral was sent on 09/12/2024. OT evaluation was performed on 09/17/2024. Review of OT evaluation on 09/17/2024, recommendation for the visit frequency was twice a week for five weeks. COTA visits 09/20/24, 09/25/24, 09/28/24, 10/03/24 and 10/05/24 were missed visit. OT skilled visits was completed only on 09/17/2024. Further review of Patient 2’s record revealed there was no interchange of coordination of care delivery with the physician of delay in OT and PT referral and OT missed visits. During home visit on 10/15/2024 at approximately 11.10 am, in an interview with Patient 2, the patient stated she has muscle weakness, and she uses walker and cane to ambulate. Patient not aware who the OT therapist is and why not providing OT services. An interview with ADM / DON on 10/16/2024 at approximately 2 pm surveyor asked why Patient #1’s PT referral was sent on 08/20/2024 when certification period started from 08/02/2024. The ADM/DON stated she did not remember she had to check. The surveyor asked why Patient #2’s OT and PT referral sent on 09/12/2024 when the certification period started from 08/21/2024. The ADM/DON stated she did not remember she had to check. The surveyor asked who is responsible to send out the referral. The ADM /DON said the OM is responsible. An interview was conducted with the ADM/DON and AADM/ ADON on 10/17/2024 at approximately 4.45 PM. The surveyor asked why OT and PT referral was not sent out per agency policy. The ADON stated RN A did the assessment and notified OM late which resulted in the agency not following its policy. The surveyor asked why Patient #1 was not provided PT and OT services and no interchange of coordination of care delivery with Patient #1’s physician. The ADON/ AADM said patient wants outpatient PT. The Physician was aware but the communication with the physician was not documented. The surveyor asked why Patient #2 was not provided OT services and no interchange of coordination of care delivery with Patient #2’s physician. The ADM/DON and AADM / ADON stated they were not aware that patient was not receiving OT services. The COTA did not inform DON or ADON. Review of agency policy titled:” Policy 4.18: Coordination of Services” of the Clinical Policy and Procedure read in part:” Policy: All skilled clinicians ……. Outlined in the plan of care. Procedure: Referrals: 6. If the evaluation is unable …... physician. 12. In an effort …... client outcome. 14. l. communicate changes …. clinicians involved in care”. Review of agency policy titled:” Patient/ Client Assessment Guidelines PE.10” revised on 05/01/24 of the Administrative Policy Manual read in part: Purpose: To provide accurate and consistent patient /client assessments. Procedure: The scope of other discipline’s assessment ……. PT, OT, SLP etc. IX. An assessment performed …... as follows: A. Nursing – 48 hours; B. Physical Therapy – four days; C. Occupational Therapy – four days; Speech-language pathology – four days; Medical Social Worker – four days”.”